Healthcare Provider Details

I. General information

NPI: 1104616853
Provider Name (Legal Business Name): CASSIE JILLIAN FIRESTONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 7TH ST
FREDERICK MD
21701-4506
US

IV. Provider business mailing address

461 PELETON ST
HAGERSTOWN MD
21740-2299
US

V. Phone/Fax

Practice location:
  • Phone: 240-566-3300
  • Fax:
Mailing address:
  • Phone: 443-253-5045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0010547
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: